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<br />l'/k�),,rrroar%ESe/(r,U.ix.��,I�.1.1.1,1,lveG<..ite.�P.il�.a.,A r etria..r..ni.af�.{bd.ldll,'v,£ru�.eEtr:oa., �eu.,,rrr,E�e((r�IPJ%A�➢,a��..
<br />STATE OF NEBRASKA
<br />?yi'itilill(eeuetA' 't,)\..r.._...._ .�.__. .._._..__.. _...----..-._� Arnr
<br />f I IIIIIN\ POIhiY ..... I r, t•ns. ...,�.cr'
<br />QQr�/{.{.1.1111)Z�z uEtpih`1,WM.r.x .<IttltlYIiLIIt,f. -
<br />< �:i't\�vzai-....._ ...:.. T..ti�:�;�G?if,-.
<br />_OPYARRI S/`IHE RAISED SEAL OF STATE OF NEBRASKA,lT CERTIFIES THE DOCUMENT BELOW T
<br />RtlE 3P f 'T ORIGINAL RECORD ON FILE WITH THE:NEBRASKA''AEPAR1 MENT OF HEALTH AND-"
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, `WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />'DATE:EIStFAVA; C'E .
<br />-612/202
<br />IN Or NEBRASKA
<br />2025O4181 2
<br />SARAH BOHNENKA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />tiEDEill's-NI:ME>;Eirst : Middle, Last, Suffix)
<br />.K iiJew an.::;:Stava
<br />4. CITYAkii-tiTATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />;;Hernia.(.yebrsks
<br />I1AL seep
<br />)7>,S6G44
<br />6b. FACILITY -NAME (If not Institution, give srrset and number)
<br />2S16::: Kihilet0t : Glide;:::.
<br />L1R:TOWN 0p00,0I:;(Include Zip Code)
<br />nd:i#land>:°'868I
<br />ia. RESIDENCE -STATE
<br />,;:;;Nebraska.
<br />9At STREET:ARO NUi*8FI
<br />2876 K)r g$on:Cit cle
<br />10w MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />9b. COUNTY
<br />Hall
<br />❑ Marrffid,butseparated ❑Widowed ❑ Divorced ❑ Unknown
<br />FAT11EWS NAME, (Fireit,':" , Mtddl
<br />Last, Suffix)
<br />13.'EVER 'IN U.S.' ARMEb`FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk.), No
<br />1G :METttlpD:OF DIPt300)
<br />Gfbmattan t; En om i»ent '
<br />•Y other(s(cify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />tCE::op DEATH
<br />!ITAL ❑.Inpatient
<br />0 ER/Outpatient
<br />❑:Dolt
<br />9c. CITY OR TOWN
<br />• Grand Island
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />faror
<br />3. DATE OP DEATF::(M ,,
<br />May 24y20?5' << `
<br />6. DATE OF ENE r#�,(tilc 1
<br />OTHER 0 Nursing Homs/LTt;
<br />I Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />be APT. NO.
<br />MI ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (Firs4, Middle, Last, Suffix) If wife,
<br />Thoedore ...Stave
<br />14a. INFORMANT -NAME
<br />Thoedore Stave
<br />1le. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12, MOTHER'S+NAME (First, Middle, Maiden Su
<br />Dot'othy ':;..: Knight
<br />lSb. LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />xatrFUNE1NAA4 HOME NAI [:AND MAILINO ADDRESS (Street, City or Town, Statter,
<br />#(I: Faitths;Ft eral Home, 2929 $. Locust Street, Grand Island; Nebraska
<br />Ftria4's::;:.
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and exan3bles)
<br />kessss, injures, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it wintery.
<br />TE CAUSE:
<br />trial cancer
<br />DUE TO, OR AS A -CONSEQUENCE OF:
<br />nNyry.Nei4atp(aony.k;.._ b).
<br />Etaer dini':IfNbEI1L1 INS cMt
<br />Wows* or Injury that InWete
<br />nh events retaking In death)
<br />8$. PART :II;:OT'IhEFtSIGNtF#OA
<br />nant,
<br />pregnant, but
<br />Onftmtvai, lf wirptant..
<br />DATE
<br />22d.1N14URY ATWORK?
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />y, Yr.)
<br />, OR AS A CONSEQUENCE OF:
<br />DITIONS-Conditions contributing to the death but.rlotrsaulditg in the.undetiying cause given In PART I.
<br />21a. MANNER OF DEATH
<br />Natural 0 HtNrdctda<
<br />❑ Accident 0 Pendinglnveniitgetieo
<br />❑ Suicide Could not bs determined
<br />22b. TIME OF INJURY
<br />21b.IIF.TRANSPORTATION INJURY
<br />Orivat/Operator
<br />!Hunger
<br />❑ Pedestrian
<br />0 other lspeclfy)
<br />22c. PLACE:hF INJt7RY-At home,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />+r ..
<br />22L LOCATION OPINJURY _})TRE
<br />UMBER, APT.NO.
<br />23a. DATE.. OF DEATH (Mo., Day, Yr.)
<br />May 24, 2025
<br />;23tI;:;DATE ED.tMo., Day. Yr.) 23c. TIME OF DEATH
<br />I41 `: z2" 2.028>, 06:27 PM /
<br />...
<br />2ad3`ti 81lIibat iit;rn)F;kdOxAid9e, death occurred at the time, dab and place
<br />itnd Sinn the>Siirea(s) shiend. ($ignatare and 1710
<br />Chad Vieth, MO
<br />TRIBUTE TO THE DEATH?
<br />PROBABLY ® UNKNOWN
<br />N ME *MAW AI'JDRE$S% CERTIFIER (Type orPrint
<br />Chad Vieth, MO, 2116 W Faktley #400;-Box 9802, Grand Island, Nebraska, 68803
<br />16a DA
<br />May 27, 202.5
<br />21C.WASANA
<br />❑ YES
<br />21d. WERE-AUTOPsy'
<br />TO COMPL6rE4U$
<br />© YES
<br />roet, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c:.PR
<br />OUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />4 mME
<br />: 24e.On ttiittrtiiie of examination andlor investigation, in my opinion
<br />the taut; date and pen and due to the causes) stated. (6tgnatuie
<br />YES
<br />CCO`ISs;:�O>W
<br />26a. HAS OR
<br />❑ YES
<br />OK Tissue 410NA410N:QEEN CONSIDERED?
<br />Ea NO
<br />28b. WAS CON
<br />Not Applicable tf
<br />26b. DATE FILED BY REGISTRAR
<br />May 29, 2025
<br />ITS
<br />
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